Literature review - The Nuffield Trust

Large-scale general practice in England: What can we learn from the literature? Literature review

Luisa Pettigrew, Nicholas Mays, Stephanie Kumpunen, Rebecca Rosen and Rachel Posaner September 2016

In collaboration with

About this report Traditional general practice is changing. Three-quarters of practices are now working collaboratively in larger-scale organisations – albeit with varying degrees of ambition and organisational integration. Policy-makers and practitioners have high hopes for these organisations and their potential to transform services both within primary care and beyond. But can we be confident that they can live up to these expectations? This report presents findings of an extensive literature review on the subject of large-scale general practice, and contributes to a stream of work by the Nuffield Trust in this area, details of which can be found at: www.nuffieldtrust.org.uk/large-scale-general-practice .

Acknowledgements We thank Judith Smith (Professor of Health Policy and Management, and Director of Health Services Management Centre, University of Birmingham) who led on the early research project development and provided comments on an early draft of the principal research study by Rosen and others (2016); Natasha Curry (Senior Health Policy Fellow) who provided guidance on this review of the literature in its initial stages; Rod Sheaff (Professor of Health and Social Services Research, Plymouth University) for his review in the final stages and helpful comments; Sally Hull and John Robson (Clinical Leads in the Clinical Effectiveness Group, Centre for Primary Care and Public Health, Queen Mary University of London) who reviewed an early draft of the sections on Managed General Practice Networks in Tower Hamlets and provided additional information; and, Michael Kidd, Ruth Wilson and Job Metsemakers (World Organization of Family Doctors) for insights into large-scale general practice internationally. We also thank Nuffield Trust staff who reviewed the report in its near-final stages: Candace Imison (Director of Policy), Mark Dayan (Policy and Public Affairs Analyst), Rowan Dennison (Editorial Manager) and Sarah Wilson (Digital Content Editor). Luisa Pettigrew is funded by a National Institute of Health Research (NIHR) In-Practice Fellowship in the Department of Health Services Research and Policy at the London School of Hygiene and Tropical Medicine. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or Department of Health. Find out more online at: www.nuffieldtrust.org.uk/large-scale-general-practice

Contents 1. Introduction

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2. Methods 6 3. Findings

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1. Which organisational forms have large-scale collaborations of GP practices adopted in England? 8

2. What are they expected to deliver?

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3. What evidence is available on their impact in England?

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4. What can we learn from initiatives with similarities?

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4. Discussion 31

Key messages

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Strengths and limitations of this literature review

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5. Conclusion 38 References 39 About the authors 46

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Large-scale general practice in England: What can we learn from the literature?

1. Introduction Reforms over the last 20 years that have encouraged collaboration among general practitioners (GPs) in England have largely focused on GPs commissioning NHS care. With the exception of out-of-hours cooperatives, general practice services have tended to be delivered by small professional partnerships, financially and administratively independent of other GP practices. Yet over the past decade GPs have started to come together in England to create new larger-scale collaborations between practices. The reasons given for this are diverse, as are the expectations placed upon them. The medical profession has played a significant role in encouraging the development of networks and federations of GP practices in England (British Medical Association, 2013; Imison and others, 2010; National Association of Primary Care, 2015; Royal College of General Practitioners, 2007, 2008 and 2013). This has come about, in part, as a result of professional objections to policy proposals, such as ‘Darzi polyclinics’, which some in the profession felt put traditional general practice at risk (Royal College of General Practitioners, 2008; Sheaff, 2013). Likewise health think tanks have emphasised the potential of scaled-up general practice groups to improve financial sustainability, extend the scope of general practice and improve the quality of care (Addicott and Ham, 2014; Goodwin and others, 2011; Rosen and Parker, 2013; J Smith and others, 2013). More recently, the potential role of enhanced collaboration within primary care and across the rest of the health sector has been recognised officially in NHS England’s Five Year Forward View (NHS England, 2014) and through the New Models of Care programme’s Vanguard sites, which include 14 multispecialty community providers (MCPs) involving large-scale collaborations between GP practices (NHS England, 2015b). An additional pilot scheme devised by the National Association of Primary Care (NAPC) and the NHS Confederation, and funded by NHS England, the Primary Care Home programme, is providing funding and support in kind to facilitate collaboration among general practices and other primary care services (National Association of Primary Care, 2015). The Prime Minister’s GP Access Fund has also catalysed the formation of general practice collaborations into legal entities in order to take on funding to improve access to general practice (MacDonald and SQW, 2015). Finally, the General Practice Forward View recently included support for federations and super-partnerships (NHS England, 2016a), and a new optional contract for multispecialty community providers involving scaled-up general practice groups with a population size greater than 30,000 is expected to be introduced in 2017 (Department of Health, 2015; NHS England, 2016b). This push for the development of larger groups of GP practices has taken place in the context of: growing patient demand in general practice and beyond; financial pressures on the NHS as a whole; increasing expectations of demonstrating quality and addressing variations in general practice care; recruitment and retention problems in general practice; and new opportunities for GPs to work differently, enabled by the policies designed to encourage general practice to play a more central role in shaping how and where services are delivered. This has also happened during a period when traditional GP practices in

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Large-scale general practice in England: What can we learn from the literature? England have perceived a threat from non-GP-owned private companies tendering for general practice services contracts through the ‘alternative provider of medical services’ (APMS) NHS contractual route that was introduced in 2004, and through the ‘any willing provider’ option for community health services which came into play in 2011 (this later changed to ‘any qualified provider’). Scaled-up general practice is expected to deliver a more sustainable model of general practice than the traditional ‘corner-shop’ model. In this paper we present the findings of a review of the literature which contributes to the Nuffield Trust’s stream of work on large-scale general practice, including the recently published findings of a 15-month mixed methods research study, Is Bigger Better? Lessons for Large-Scale General Practice (Rosen and others, 2016). We aim to answer the following questions: 1. Which organisational forms have large-scale collaborations of GP practices adopted in England? 2. What are they expected to deliver? 3. What evidence is available on their impact in England? 4. What can we learn from initiatives with similarities?

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2. Methods An iterative process was used to identify relevant literature to answer each of the four questions set out on the previous page. Initially, a scoping review was undertaken of NHS England policy documents, health think tank publications, and guidance published by professional bodies about new forms of collaboration between GP practices in England in order to identify which organisational forms were described and what they were expected to achieve (Questions 1 and 2). We also searched for evaluations of clinical networks commissioned by the Department of Health (England), and the National Institute of Health Research, Health Services and Delivery Research programme. References in these documents were screened for relevance, and experts in primary care and health services research were asked for advice on potentially relevant sources of information. During these processes, 135 relevant texts were reviewed, covering academic articles, grey literature (for example reports, policy documents and professional guidance), news articles and websites. Based on the information gathered during the initial scoping review, a search strategy was developed with the help of a librarian who specialises in health services research (Rachel Posaner). This aimed to capture literature evaluating forms of large-scale general practice provider collaborations (Question 3). By ‘large scale’ we refer to new collaborations typically of more than three GP practices, which, with the exception of out-of-hours care, would previously have worked largely independently of one another in order to provide care. Four databases were searched – Medline, SSCI, Embase and HMIC – between 1996

Box 1: Inclusion and exclusion criteria used for Question 3 Inclusion criteria: • Study evaluates the impact of new forms of collaboration between GP practices in England focused on the provision of care (for example general practice networks, federations, super-partnerships or multi-site practice organisations). • Study evaluates actions of three or more GP practices working collectively. • Study reports on the impact of one or more of the following as a result of the collaboration: processes and indicators of quality of care, clinical outcomes, patient experience, workforce satisfaction, or costs. Exclusion criteria: •

Study includes new forms of collaboration between GP practices at scale in England, but evaluation of the collaboration’s impact is not a focus of the research (for example integrated care initiatives and the Prime Minister’s GP Access Fund where the impacts of new forms of general practice collaboration cannot be disentangled from the impact of the rest of the initiative).

• Study does not contain primary data. • Descriptive case studies without clear methodology and/or with only self-reported impacts.

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Large-scale general practice in England: What can we learn from the literature? and 2016. After the exclusion of duplicates, the titles and abstracts of 1,442 articles were screened and 46 of these were read in full. References from relevant academic articles identified in this search were screened. In order to address Question 3, on the impact of new forms of large-scale general practice collaboration in England, the inclusion and exclusion criteria outlined in Box 1 were used to identify evidence. These criteria aimed to identify studies which were methodologically robust. Further academic and grey literature were identified through further iterative searching, including the recommendation of experts in the fields of primary care and health services research. This enabled the capture of additional evaluations of new models of general practice which may not have been picked up by the database search. In reviews of complex evidence, this process of ‘snowball’ searching and seeking guidance from experts has been shown to increase the yield of relevant results (Greenhalgh and Peacock, 2005). This process also aimed to identify further major evaluations or reviews of GP-led commissioning, clinical networks, integrated care initiatives and out-of-hours general practice cooperatives in England which were identified to have similarities with the processes required to form new general practice provider collaborations and/or their objectives, as well as relevant international literature which contributed to the evidence in order to answer Questions 4. In this process, a further 159 texts were reviewed, including academic papers and grey literature. Systematic collection and assessment of the quality of the literature was not undertaken to answer Question 4, which looked at literature in England and other countries. However, greater consideration was given to systematic reviews, peer-reviewed empirical research, and government-commissioned independent evaluations of relevant national programmes. A narrative approach was taken to synthesise the literature. Thematic analysis was used to identify recurrent themes which emerged in the literature on initiatives with similarities, in order to answer Questions 4 and to draw key lessons in the discussion.


3. Findings 1. Which organisational forms have large-scale collaborations of GP practices adopted in England? Various terms have been used to describe new forms of large-scale collaboration between GP practices focused on the provision of care in England, including: GP groups, clusters, consortia, family care networks, networks, federations, alliances, joint ventures, superpartnerships, multi-practice organisations and community health organisations (Addicott and Ham, 2014; British Medical Association, 2015a; Care Quality Commission, 2015; Curry and Kumpunen, 2015; Imison and others, 2010; J Smith and others, 2013).

Figure 1: Spectrum of forms of large-scale general practice collaborations

Loose ties between members/ contracts held by practices

Organisational form of core contract Network • No formal ties: practices maintain GP contracts • No executive function • Share principally intangible objectives Federation • Growing ties: practices maintain GP contracts, but some have legal agreements for joint activities (and pool some income/risk) • Employ an executive function • Share organisational goals, but practices may have independent goals

Legal structure for joint working

Partnership

• Traditional partnership

agreement

• Limited liability

partnership

Company

• Company limited by

shares

• Company limited by

Tight ties between members/ contracts merged

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Super-partnership • Close ties: practices merge GP contracts • Employ an executive function and management team • Organisational goals become practice goals • Pool all/most income/risk

guarantee

Social enterprise

• Community interest

company

• Industrial and provident

society

• Charitable incorporated

organisation

Multi-site practice organisation • Tight ties: directors hold all GP contracts • Employ an executive function and management team • Organisational goals are practice goals • Pool all/most income/risk

Source: Rosen and others, 2016, who built on the typology originally developed (J Smith and others, 2013).

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Large-scale general practice in England: What can we learn from the literature? The terms have not always been used consistently, and the governance structures underlying the various models are notably heterogeneous. However, in essence, they can be considered to be a spectrum of forms of collaboration between GP practices that exhibit different degrees of financial and administrative interdependency, as shown in Figure 1. Conceptually the models can be differentiated in terms of what they do with their core general practice contract, and/or what legal form they adopt to undertake other activities. With regard to the core contract, at one end of the spectrum there are loosely associated networks of GP practices with goals that are largely intangible, such as the informal exchange of information. The participating GP practices remain independent of one another. Next are federations, which are still considered networks from the organisation perspective of organisational theory, but they have growing ties and more formal agreements between practices to undertake joint activities than networks. Federations often pool part of their existing income in order to support back-office functions, or set up a new legal entity in order to tender for community health services contracts. In super-partnerships, a new partnership agreement is put in place between partners of existing practices – and partners form part of the board of the new organisation. A small number of partners may be nominated to form an executive group to make day-to-day decisions and guide strategic decisions to be approved by the larger group. General practice contracts may continue to be managed by each individual practice, although responsibility for these will lie ultimately with the new partnership via the partnership agreement. Alternatively, the GP contracts may be handed over to a designated executive with agreement regarding how the funds will be redistributed and how partners will be paid. In multi-site practice organisations (MPOs), the organisation grows through taking over practices, often where partners are retiring or NHS contracts have been put out to tender. In this case, the partnership or company may hold more GP contracts than would traditionally have been the case, and is likely to have a central leadership and management team making all strategic decisions. Although a network of practices exists within a super-partnership or an MPO, arguably they are no longer considered a ‘network’ from the organisation perspective of organisational theory, but would instead be regarded as a single organisation. These different forms of general practice collaborations are not mutually exclusive. For example, federations can take on new practices, as MPOs typically would, through setting up a separate legal entity. The same group of GP practices, who may or may not have merged their core GP contracts into a single organisation, may have more than one governance arrangement or legal structure for different activities. Legal structures include various forms of partnership agreements, private companies and social enterprises. Each provides different limits to liability, profit status and re-investment/distribution requirements; opportunities to hold General Medical Services, Personal Medical Services or APMS NHS contracts; and access to the NHS pension scheme (British Medical Association, 2015b). It also is possible for a GP practice to be part of a local general practice network, for example, but also belong to an MPO that has practices that fall into different clinical commissioning group (CCG) areas – resulting in complex governance structures. The majority of collaborations are currently reported to be at the network-federation end of the spectrum, with super-partnerships and MPOs currently estimated to represent under five per cent of these new forms of large-scale general practice collaboration (Kumpunen and others, 2015).

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2. What are they expected to deliver? Review of NHS England policy documents, and publications from GP professional organisations and health think tanks identified wide-ranging expectations for new forms general practice collaborations. These documents outline how these collaborations are expected to enable changes through a number of mechanisms, which would ultimately improve the sustainability of general practice and patient outcomes. Theoretical expectations of what large-scale general practice may deliver, and how, are presented below under four headings, although some mechanisms, such as investing in information technology (IT) or improving patient and public involvement, are cross-cutting: • Strengthen the workforce, for example through: developing joint standardised training and education in particular for ongoing professional development; enabling peer support and competition; investing in a more diverse workforce; sharing staff when needed; and improving opportunities for career progression for all staff. • Increase access and extend services, for example through: extending opening hours; introducing new routes of access; enhancing the capacity of practices to offer specialist services in the community; improving clinical pathways; delivering integrated care in partnership with other actors, including secondary care, social care, and private and/ or voluntary sectors, through joint contracting or capitated budgets; and improving patient and public involvement. • Improve clinical quality and reduce variation, for example through: strengthening clinical governance; standardising procedures; investing in technology; stronger performance monitoring and feedback; spreading best practice; and adopting a population-based approach to services. • Improve financial sustainability of practices by creating efficiencies and economies of scale, for example through: common back-office functions; shared training and staffing; task shifting within the workforce; joint investment in technology; better integration of care; and purchasing, providing and commissioning at scale. (Addicott and Ham, 2014; Goodwin and others, 2011; Imison and others, 2010; National Association of Primary Care, 2015; NHS England, 2014 and 2016b; Roland and others, 2015; Royal College of General Practitioners, 2007, 2008 and 2013; Rosen and Parker, 2013; J Smith and others, 2013). Ultimately, these changes aim to modernise the traditional ‘corner shop’ model of general practice and provide a stronger collective voice for general practice in the local health care system. The expectations placed on these new forms of collaboration are significant and ambitious; therefore it is important to understand what evidence there is that they will be able to deliver.

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3. What evidence is available on their impact in England? Various health think tank publications were identified that describe new models of general practice collaboration via a selection of case studies (Addicott and Ham, 2014; Imison and others, 2010; Rosen and Parker, 2013; J Smith and others, 2013). These reports are largely designed to provide guidance on the formation of the new models and describe potential or real innovations in workforce, technology or quality improvement, but do not offer a robust evaluation of their impact. Grey literature such as news articles were also identified which provide self-reports of the development and impact of these new models of general practice collaboration (Barr, 2016; Evans, 2016; Royal College of General Practitioners, 2016b and 2016c; M Smith, 2015). However, grey literature did not meet our inclusion/ exclusion criteria for this question, which aimed to identify studies which analysed primary data and were methodologically robust (see Box 1 on page 6). Recent papers evaluating integrated care initiatives in England also indirectly examined the impacts of new general practice collaborations since these were present in some of the sites studied; however, it was not possible to disentangle the impact of larger-scale general practice collaborations in these studies from the impact of the wider integration of care initiatives (Erens and others, 2015; RAND Europe and Ernst & Young LLP, 2012; Sheaff and others, 2015). Similarly, evaluations of the first wave of the Prime Minister’s GP Access Fund (which provided £50 million in 2014 to improve access to general practice across 20 pilot sites in England) involved new forms of collaboration between GP practices as networks, federations and/or new legal entities in around half of the pilots (MacDonald and SQW, 2015). The first evaluation report outlined how the GP Access Fund catalysed the development of several of these new forms of collaboration and acknowledged their contribution in increasing access for patients through, for example, shared extended-hours clinics. However, this initial evaluation report only provides aggregated results across all the pilot sites. It was therefore not possible with the report which is currently available to unpick the impact of the larger-scale general practice collaborations from the effects of various other interventions which took place across sites. Evaluations of these initiatives therefore did not meet the inclusion criteria to answer Question 3. They have, however, helped inform the answer to Question 4, because they offer a degree of proof-of-concept of various large forms of networks or organisations. Only five research studies were identified that met the inclusion/exclusion criteria for Question 3. Four used quantitative methods in the same managed general practice networks in the London Borough of Tower Hamlets to evaluate the impact of intervention packages on quality of care and clinical outcomes. They also reported some cost data (see Table 1; Cockman and others, 2011; Hull and others, 2013 and 2014; Robson and others, 2014). One qualitative study examined a nationally-dispersed MPO with 50 GP practices (Baker and others, 2013). This study evaluated quality and safety processes, and provided staff views on their job satisfaction and staff views on patient experience (see Table 2).

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Large-scale general practice in England: What can we learn from the literature? Q uantitative studies: Tower Hamlets Managed General Practice Network In 2008/09, Tower Hamlets Primary Care Trust (PCT) (population approximately 260,000) established eight geographically defined, managed general practice networks with 4–5 GP practices each (population approximately 30,000–50,000). Through these networks, packages of care in four clinical areas were delivered between 2009 and 2012: childhood immunisations; type 2 diabetes; chronic obstructive pulmonary disease (COPD); and cardiovascular disease (CVD). Tower Hamlets was also one of the Integrated Care Pilots and later Integrated Care and Support Pioneer sites evaluated (Erens and others, 2015; RAND Europe and Ernst & Young LLP, 2012). Each network employed a manager, clerical staff (for example a recall coordinator) and had an educational budget. Care packages were rolled out between 2008 and 2010, with all eight networks functioning by April 2010. Previous local enhanced services’ funding was channelled into the development of the networks and incentives for packages of care. This came to approximately £10 million per annum in total across all networks. Funding for incentives was distributed at network level by the PCT rather than to individual practices, in order to encourage peer scrutiny and the collective management of funds. Each network had autonomy to use funds to achieve their key performance indicators (KPIs) and decide how these would reach individual practices (Robson and others, 2014). It should be noted that although referred to as networks, the shared financial rewards and collaboration needed to achieve these, meant that the collaboration of GP practices in Tower Hamlets are conceptually more similar to federations than networks, as illustrated in Figure 1 on page 8. The four studies examined the impact of the implementation of the four care packages across the networks. The packages of care involved complex interventions which partly depended on the existence of the network, including education for staff, financial incentives distributed at network level, IT-enhanced recall systems, standardised data collection, comparative feedback on performance and management across the networks. The programmes were developed by local GP clinical leaders, public health teams, PCT managers and had input from McKinsey management consultancy. The Clinical Effectiveness Group (CEG) based at the local university and led by local GPs developed the dashboards and measurable KPIs. They also undertook the evaluation of the interventions. Findings of the research studies are presented in Table 1.

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Table 1: The impacts of a large-scale general practice collaboration from quantitative studies (Tower Hamlets Managed General Practice Network) Authors and journal

Title of paper

Study methods

Care package facilitated by Tower Hamlets Managed General Practice Network

Key performance indicators

Reported impact on processes and indicators of quality of care

Reported impact on costs

Cockman and others (2011), BMJ

Improving MMR vaccination rates: herd immunity is a realistic goal

Observational study. Time-series analysis. Comparison with trends in London and England

– Financial incentives – Standardised recording of data – Systematic call and recall with IT – Monthly dashboard feedback on performance – Training and education for clinicians – Active follow up of defaulters – Regular meetings for peer review and ideas sharing

– Achieve 95% uptake of all Uptake of first MMR1 vaccine childhood immunisations before age 2 rose from 80% in Sept 2009 to 94% in March 2011

Total for 8 networks: £112,000 (used as financial incentive; £14,000/network)

– Financial incentives – Standardised recording of data – Systematic call and recall with IT – Monthly dashboard feedback on performance – Bi-monthly multidisciplinary team (MDT) meetings with diabetic specialist team – Supported case management and education – Rapid access to consultants via email or phone

– Number of care plans completed, target: 90%

Rise in care plans from 10% in Q1 2009 to 88% in Q1 2012

– Proportion of patients attending retinal screening, target: 80%

Rise in retinal screening from 72% in Q1 2009 to 82.8% in Q1 2012 – Step change catch-up with London and England (no P value)

Intervention phased in Sept 2009 – Jan 2010 Period of data analysis presented quarterly between Q1 2006 and Q3 2010 (MMR1 vaccination)

Hull and others (2013), BMJ Quality and Safety

Improving outcomes for patients with type 2 diabetes using general practice networks: a quality improvement project in East London

Observational study. Time-series analysis. Comparison with trends in two neighbouring PCTs, London and England Intervention phased in Oct 2009 – Apr 2010 Period of data analysis presented yearly 2007–2012 (retinopathy screen) 2006–2012 (total cholesterol) 2006–2012 (blood pressure) 2005–2012 (HbA1c)

Step change in rate of increase of MMR1 compared to before and after (P£200,000/ network) 70% in advance, 30% dependent on performance

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Title of paper

Study methods





Hull and others (2014), Primary Care Respiratory Medicine

Improving outcomes for people with COPD by developing networks of general practice: evaluation of a quality improvement project in East London

Observational study. Time-series analysis. Comparison with trends in London and England.

– Financial incentives – Standardised recording of data (including co-morbidities, medication review, encourage non-pharmaceutical interventions) – Systematic call and recall with IT – Active follow up of non-attenders – Monthly dashboard feedback on performance – Regular patient review – Quarterly MDT meeting including respiratory consultant and community respiratory team – Supported case management and education – Community-based pulmonary rehab – Hospital admission avoidance service – Rapid access to consultants via email or phone

– Increase number of COPD cases on network registers: target 10% increase in first year – Increase in number of care plans: target 80% – Increase in referrals to community-based pulmonary rehab: target 75% in patients with Medical Research Council (MRC) score ≥3 – Improve influenza vaccination (no target, not financially incentivised as already incentivised by Quality and Outcomes Framework; QOF) – Reduce smoking prevalence (no target, not financially incentivised as already incentivised by QOF) – Reduce emergency hospital admission for COPD (no target, not financially incentivised, only tracked)

COPD register increased by 21% between 2010 and 2013

Total for 8 networks: £300,000/annum for 3 years

Intervention phased in Apr 2010 – Jun 2010 Period of data analysis presented yearly 2010–2013 (annual review) 2005–2013 (flu vaccination) 2005–2011 (COPD admissions)

Annual reviews and care planning increased from 53% in 2010 to 86.5% in 2013 Pulmonary rehab in patients with MRC score ≥3 increased from 45% in 2010 to 75% in 2013. No national comparator Flu vaccination high prior to intervention, showed ‘steady improvement’. In 2012 it was ‘significantly higher’ than rate in England No improvement in smoking prevalence: in 2010 39% of patients with COPD smoked; in 2013 40.4% smoked Emergency COPD admissions ‘have fallen’ but remain higher than London average. Trend suggests a step-change compared to London and England trends

70% in advance, 30% dependent on performance

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Title of paper

Study methods





Robson and others (2014), British Journal of General Practice

Improving cardiovascular disease using managed networks in general practice: an observational study in inner London

Observational study. Comparison with trends in two local PCTs, London and England Intervention phased in 2008 – Apr 2010

– Financial incentives – Systematic call and recall with IT – Standardised recording of data – Monthly dashboard feedback on performance – Three whole-time community specialist CVD nurses across all networks – Training for practice nurses – Clinical guidelines developed by local clinical effectiveness group

– BP